Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
Blue Shield of CaliforniaCommercial · Coverage · Medical Policy · CA · Plastic Surgery, OncologyMedium impact

Reconstructive Breast Surgery/Management of Breast Implants (7.01.22)

Effective date
Oct 1, 2026
Identified
Oct 2, 2026

Summary

Blue Shield of California medical policy 7.01.22 on reconstructive breast surgery and management of breast implants has an effective date of October 1, 2026. The annual review updated the policy statement, guidelines and literature review. Reconstructive breast surgery may be considered medically necessary after a medically necessary mastectomy, accidental injury or trauma. Explantation of a silicone gel-filled implant may be considered medically necessary for documented rupture, infection, extrusion, Baker class IV contracture, or as an adjunct to surgical treatment of breast cancer. A saline-filled implant follows similar indications, and a documented rupture qualifies only when the implant was originally placed for reconstructive purposes. Preventive explantation to reduce remote risk of anaplastic large cell lymphoma, B cell lymphoma or squamous cell carcinoma is listed as investigational.

Get alerts when payers change rules like this one

We check Blue Shield of California and other payers every day and email you when a change matches your specialty and state.

Get Blue Shield of California alertsPolicy Monitoring is free. No card required.

What to do

Action · 6 steps
01Already effective October 1, 2026: Billing team, for explantation claims, document in the history and physical or consultation notes the clinical indication for removal including Baker class if applicable, the reason the implant was originally inserted, and the type of implant being removed.
02Attach operative and radiological reports where applicable, and for reconstruction include breast implant related operative reports after the service.
03A claimed implant rupture requires documentation with an imaging study such as mammography, magnetic resonance imaging or ultrasonography.
04Pain as an isolated symptom is an inadequate indication for explantation, so the pain must relate to the Baker classification or a diagnosis of rupture.
05The procedure may be denied as not medically necessary when it is likely to result in only minimal improvement in appearance, when the treating surgeon cannot or will not provide sufficient documentation including medical quality color photographs, when there is alternative approved medical or surgical intervention with equal or superior clinical outcomes, or when the procedure is for cosmetic purposes only.
06Questions about applicability go to the Prior Authorization Department at (800) 541-6652.

Codes mentioned

193251932819330193401934219350193571936119364193671936819369193701937119380C1789L8030L8033L8039L8600S2066S2067S2068

Original notice

Reconstructive Breast Surgery/Management of Breast Implants (7.01.22)
blueshieldca.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Shield of California changes →
Cosmetic and Reconstructive Procedures (BSC7.08)MediumEffective Nov 1, 2026 · Medical PolicyBrowse every Blue Shield of California change in the policy list

Related policy hubs

Blue Shield of California policiesCA policy changesPlastic SurgeryOncologyCode 19325Code 19328Code 19330Code 19340Code 19342Code 19350Code 19357Code 19361Code 19364Code 19367Code 19368Code 19369Code 19370Code 19371Code 19380Code C1789Code L8030Code L8033Code L8039Code L8600Code S2066Code S2067Code S2068

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account